Trump made two big moves this week to reshape the Affordable Care Act: Shots

In less than 12 hours last week, the Trump administration took two seemingly contradictory measures that could have a profound impact on the insurance markets set up by the Affordable Care Act.

Health analysts say that at least one of the efforts, along with previous changes initiated by the administration, could help transform the insurance market to be much more similar to what it is. it was before the coming into force of the 2010 federal health act – one the protections varied widely across the United States.

The first move this week took place Monday morning, when Trump's health officials issued guidelines that could undermine the exchanges put in place for people who buy their own health insurance. Administration guidelines allow states to more easily bypass certain ACA requirements; among other things, Trump's advice would allow the use of federal grants for smaller plans that may reject people with pre-existing health conditions.

Trump's second decision – a rule proposal unveiled Monday night – could bolster the health of ACA's markets by sending millions of people on job-related hedging to the stock markets, armed with the money they've been given. employers to buy individual plans.

Both efforts play in parallel narratives – one of the Republicans and the other of the Democrats – who are dominating the bitter political debate of the parties on the ACA.

Frustrated by the fact that a Republican-controlled Congress could not repeal the Affordable Care Act, the Trump administration continued to undermine this law by weakening markets and protecting consumers, say some critics and specialists in health policy.

Trump's efforts make it easier for insurers to offer smaller contracts that violate the rules of the law, such as coverage for people with pre-existing illnesses, or the prohibition of annual or life-time limits. that the insurers will pay.

Congress also canceled the tax penalty imposed on Americans who do not register for health insurance as of next year. Together, these changes could reduce the number of registrations to ACA health plans, potentially increasing the premiums for those who stay.

The administration and Republicans in Congress say that they are looking to help those who are left behind by the ACA – those who do not receive subsidies to buy health insurance and who are desperately seeking cheaper options – even if that allows them to buy a less solid coverage

Even without repealing the ACA, Republican efforts are shifting control of health insurance policy decisions to states, say policy analysts.

"Some states will do everything in their power to keep individual markets strong and stable. Others will not, "said Sabrina Corlette, a research professor at the Center on Health Reform Reforms at Georgetown University.

So what expectations should consumers have? Analysts say that there are three points to remember:

Protections for pre-existing health problems are uncertain

Polls show that adherence to ACA safeguards for people with health problems is a major concern for Americans. Democrats have made the defense of health law an essential part of their mid-term election campaigns.

The Republicans got this message. Even those who voted for the repeal of the ACA or joined a lawsuit of 20 red states to cancel the federal law now declare wanting to protect people with pre-existing diseases. Yet government lawmakers have not presented any plan as protective as the law in force.

In August, the administration released a rule allowing expanded use of short-term health plans that are less expensive than ACA policies. To get these prices lower, most of these plans Do not include insurance coverage for prescription drugs, maternity care, mental health or drug treatment.

Relocation is unlikely to benefit people with chronic conditions, as short-term plans can reject people with pre-existing conditions or refuse to take care of those medical problems.

Under the rule, insurers can sell these short-term contracts (which can be sold as early as next month) for up to one year, with a renewal option for up to three years. This cancels a directive dating back to the Obama era that limited the duration of such policies to a maximum of 90 days.

Administration officials estimate that such plans could attract 600,000 new enrollees next year, and others felt that the number could be much higher. The problem is that while many healthy people in 2019 were pulling out of the ACA market – it is estimated today at about 17 million the number of enrolled – and choose short-term plans , premiums will increase for those remaining in the ACA market. This would increase the premiums for people with pre-existing conditions. This would also make the ACA market less attractive to insurers and could cause them to stop offering stock market plans.

In which state do you live

One of the most important changes introduced with the ACA has been a set of standard rules in all states.

Prior to the coming into force of the law, consumers who bought their own blanket saw great differences between what was offered and the protections they enjoyed, depending on the state in which they lived.

Most states, for example, have allowed insurers to dismiss claimants with health problems such as diabetes, cancer, depression, Down syndrome or asthma.

Some states have required insurers that they charge similar premiums in all areas, but most have allowed a large variation in the amount of premium charged to a client, depending on age, gender or health. Some lean plans did not cover prescription drugs, chemotherapy or other medical services.

By standardizing rules and benefits, the ACA has prevented insurers from rejecting applicants with health problems and charging them higher premiums. The ACA ensures that women can not be charged more than men for the same health policy, and insurers are allowed not to charge seniors for more than three times the amount billed to younger applicants.

But according to new guidelines released this week that give states more flexibility over what is on offer, consumers could again see a wide variation in coverage, premium rules and even eligibility for subsidies.

"This is putting pressure on politicians," said Caroline Pearson, a senior fellow at NORC, a non-partisan research institution at the University of Chicago. "You risk doing it [constituents] worse by threatening these markets, "says Pearson. It will always be difficult. "

Millions of others are likely to join the ranks of "buy-your-own"

The proposed rule released Tuesday allows employers to fund tax-free accounts – called health expense reimbursement arrangements – that workers can use to purchase their own coverage in ACA markets.

According to the estimates of the administration, about 10 million people will do it by 2028, which will constitute a substantial boost for the federal and state ACA exchanges, which, according to the decision-makers, do not have the same effect. have never reached the number of listings needed to attract enough insurers and keep prices down.

John Barkett, senior director of political affairs at Willis Towers Watson, a benefits consulting firm, said he expects some employers are now considering "seriously" to rely on a public or federal health insurance system to provide health insurance to their workers. And if they do, the injection of workers will improve the options within these insurance markets, attracting more insurers, says Barkett.

"These people who come will be sponsored by their employer, they will have stable jobs," notes Barkett, and will likely stay with longer coverage than those generally available on the market.

Currently, about 17 million people buy their own health insurance, and about 10 million of them use federal or regional ACA markets to do it. Others buy private plans through brokers.

The rule proposed by Trump will not be finalized for several months, but it could result in new options by 2020.

If these workers seeking coverage are generally in good health, the injection could slow down the premium increase across the ACA market as it would improve the risk pool for insurers.

However, if employers whose employees are primarily older workers or whose costs are higher choose to adapt to the markets, this could help increase premiums.

In a strange sense, the Administration notes in its proposed rule that CAA contains provisions that may protect the market from this type of adverse selection, which may result in higher prices. But most of the protection factors cited by the rule have expired or have been weakened or removed by Trump or Republican-controlled Congress – such as the tax penalty for uninsured and federal grants to insurers to cover lower deductibles for some low-income consumers. .

Benefits consultants and health policy specialists are skeptical about the number of companies that will switch to an HRA plan, given the tight job market. Analysts believe that lingering uncertainty about the fate of the ACA market could prompt them to send workers themselves to search for health insurance.

The health benefits package that a company offers its employees is now an important factor in its ability to attract and retain workers, said Chris Condeluci, a lawyer in Washington. Previously, he worked for Senator Chuck Grassley, R-Iowa, and was advisor to the Senate Finance Committee when drafting the ACA.

"Most employers believe that their group health plan will provide better health coverage than an individual market plan," said Condeluci.

Kaiser Health News, a non-profit news service, is an independent editorial program of the Kaiser Family Foundation, and not affiliated with Kaiser Permanente.